Back Pain and Sciatica Over 60

Leg pain that comes from your back is frightening at any age. The pain goes somewhere it should not. Bits of your leg go numb. And most people quietly wonder whether a nerve is being permanently damaged.

Let me deal with that first. Nerve pain is not the same as nerve damage. An irritated nerve is a noisy nerve. Burning, tingling and numbness are it misfiring, not failing.

Now the part that makes this guide different from the one I give younger patients. After sixty, leg pain from the back has two common causes rather than one, and they behave differently, respond to different things, and need different advice.

Working out which one you have is the single most useful thing in this guide. Section 4 does that, and it takes two minutes to read.

There is also a third possibility that is not your back at all, and it matters. That is section 5.

This guide is not saying your pain is in your head. Your pain is completely real.

One thing before you start. This guide assumes I have examined you and ruled out the serious causes. There is one genuine emergency attached to this. If nobody has examined you, read section 14 first.

The short version

• Pain is an alarm. It protects you. It does not measure damage.
• Nerve pain is not nerve damage. Numbness and tingling usually fade, though slower than the pain.
• After sixty there are two common causes of leg pain from the back. What relieves it tells us which. See section 4.
• If walking brings it on and sitting or leaning forward relieves it, that is a different problem from a disc, with a different plan.
• Narrowing on a scan is common and usually causes no symptoms at all. Only about 1 in 10 people with it ever get symptoms from it.
• Losing strength and fitness is a bigger threat to you than anything on your scan. And you can get both back at any age.
• Surgery is a reasonable option for some people. It is a decision about what you can do, not about what a scan looks like.
• There is one emergency to know about. Section 14 tells you what to watch for.

1. Pain is an alarm, not a damage meter

Your body has danger sensors. They fire when tissue is stretched, squashed or irritated. They send warning signals to your spinal cord, and then to your brain. None of that is pain yet. It is just information.

Then your brain weighs that information against everything else it knows. What were you doing? What happened last time? What do you think this means? How stressed are you? Did you sleep?

Then it decides: how much danger am I in, and how much pain does this person need to feel to keep them safe?

Pain is the answer. Your brain produces it.

That is why damage and pain match up so badly:

• A paper cut really hurts. There is almost no damage.
• Soldiers get badly hurt and feel very little until they are safe.
• People who have lost a leg can still feel pain in it.

So how much pain you feel does not tell you how much damage there is. It tells you how protective your body is being right now.

2. The pain gate

In 1965, two researchers called Ronald Melzack and Patrick Wall came up with an idea that changed pain medicine. It is still one of the most useful pictures we have. Picture a gate in your spinal cord. Warning signals have to pass through it to reach your brain.

When the gate is open, lots get through and you feel more pain. When it is closed, fewer get through and you feel less. Nothing in your back has changed. Only the gate has.

What closes the gate

• Touch, rubbing, heat and hands-on treatment. Touch signals travel on bigger, faster nerves than danger signals, and they crowd them out.
• Moving and exercise. They release your body's own painkillers.
• Feeling safe and calm.
• A decent night's sleep.
• Company. Being lonely genuinely makes pain worse, and it matters more in later life than most people admit.
• Understanding what is going on. Reading this counts.

What opens the gate

• Stress and worry, especially worrying that a nerve is being damaged.
• Broken sleep.
• Low mood, and feeling written off because of your age.
• Fear of falling, which is one of the most powerful gate openers there is after sixty.
• Being afraid to move.
• Being told frightening things about your spine. Crumbling, worn out and bone on bone all do real harm.

Here is the key bit. Your brain does not just receive signals at that gate. It sends signals down and changes the settings.

3. When the alarm gets too sensitive

When a pain system has been busy for months or years, it does not wear out. It gets better at its job. The sensors fire more easily. The spinal cord turns signals up. The brain decides there is danger more quickly.

Think of a car alarm. When it was fitted, it went off if someone tried to force the door. Years later it goes off when a cat walks past.

The alarm is not broken. It is not lying. It is just set far too sensitive for the actual level of threat.

Because your body learned it, your body can unlearn it. There is no age limit on that. Studies of pain education and gradual activity show benefit in people in their seventies and eighties.

4. Which kind of leg pain do you have?

This is the most useful section in the guide. What matters most is not where it hurts. It is what makes it better.

Pattern one: from a disc

• It came on relatively suddenly, over days.
• The pain is there most of the time, not just when you walk.
• Sitting makes it worse. So does bending forward, and getting out of a car.
• Standing or lying down often eases it.
• Usually one leg, often a clear line of pain running down it.
• Coughing or sneezing can shoot it down the leg.

Pattern two: from narrowing, called spinal stenosis

• It came on gradually, over months or years.
• Your back may be fine at rest.
• Walking brings it on, after a fairly predictable distance. So does standing upright for a while.
• Your legs feel heavy, tired, achy, numb or weak rather than a sharp line of pain.
• Sitting down or leaning forward relieves it, usually within a few minutes.
• You can push a shopping trolley much further than you can walk upright.
• Cycling is easier than walking. Going uphill is easier than going down.
• Often both legs, though it may be worse on one side.

The reason bending forward helps is simple. It opens up the space around the nerves. That is why the trolley works, and why you may find yourself resting on a gate on a walk.

Plenty of people have some of both. These are clues, not a diagnosis, and it is my job to sort it out properly. But if you tell me exactly what relieves it, you have given me most of the answer.

5. The one that is not your back at all

There is a third cause of leg pain on walking, and it is important not to miss, because it needs a different sort of attention altogether.

Narrowed arteries. The leg muscles are not getting enough blood when they work.

• The clue is what relieves it.
• With narrowing in your spine, you need to sit down or lean forward. Standing still upright does not help much.
• With a circulation problem, simply standing still is enough. You do not need to sit or bend.

Other clues pointing to circulation: it is usually felt in the calves, it is worse going uphill rather than better, and your feet may feel cold or look pale. It is more likely if you smoke or used to, or have diabetes, high blood pressure or heart disease.

If that sounds like you, please see your GP. It is checked with a simple test and it is worth knowing about, because it says something about your circulation generally, not just your legs.

6. What scans show at your age

Researchers scanned people who had no back pain at all and counted what showed up.

• At 60, about 9 in 10 had disc degeneration. At 80, nearly everyone.
• At 60, about 7 in 10 had a disc bulge.
• Worn facet joints and a bone slipped slightly forward on the one below are both common in people your age with no symptoms.

Now the figures that matter most for this guide.

Narrowing of the spinal canal is common, and usually silent. In people with no symptoms at all, roughly 1 in 10 have narrowing visible on a scan. Among people in their sixties, around 1 in 5 have some degree of it.

And of the people who have narrowing on a scan, only about 1 in 10 ever develop symptoms from it.

Read that again. Most people with stenosis on their scan do not have stenosis as a problem. Which is exactly why the report is not the diagnosis, and why what relieves your pain tells us more than the picture does.

A scan does earn its place here if we are considering surgery, because then we need to know precisely which level and why. As a routine explanation, it mostly hands you frightening words. If you have already had one and been given some, bring the report in.

7. If it is a disc

Here is the genuinely reassuring part. Herniated discs shrink on their own, and the worse they look, the more likely they are to shrink.

Researchers pooled the studies that scanned people and rescanned them later:

• A sequestration, where a fragment has broken off completely and the worst kind on paper: 96 in 100 shrank. In 43 in 100 it vanished entirely.
• An extrusion: 70 in 100 shrank.
• A protrusion: 41 in 100.
• A simple bulge: 13 in 100.

When disc material escapes and meets your blood supply, your body treats it as something that does not belong and clears it away. The more dramatic the escape, the more there is to mop up.

Most people improve substantially over weeks to a few months. The pain usually settles before the numbness does, and numbness can linger for months afterwards. That is expected, and it is not a bad sign.

8. If it is narrowing

Different condition, different expectations, and mostly better news than people assume.

It is not an emergency and it is not a countdown to a wheelchair. The natural course in most people is stable or slowly changing rather than steadily worsening. A study that followed people for ten years found around half of those managed without surgery had a good or reasonable result.

The thing to protect is your fitness. The trap is obvious: walking brings on symptoms, so you walk less, so you get less fit and weaker, so you can do even less. That downward spiral does more damage to your life than the narrowing does.

So work within the pattern rather than against it:

• Walk in chunks. Stop and sit before the symptoms build, not after. Three lots of ten minutes beats one painful thirty.
• Use the forward lean. A trolley, a walking frame, poles, or simply resting forward on a wall or gate for a minute.
• Cycle. A stationary bike is often the single best way to keep your fitness up, because sitting forward opens the space.
• Strength work. See section 11. This matters more than anything else on the list.
• Swimming, if you have access to it. Losing fitness is the thing to avoid. Everything else is negotiable.

9. Surgery, and when it helps

Some people ask about it straight away. Others are frightened of it. Here is the honest picture.

For a disc, surgery relieves leg pain and does it faster than waiting. But trials following people for a year or two found both groups ended up in much the same place. So it is usually a decision about how fast you get there and how much you can bear meanwhile, not about where you end up.

For narrowing, the picture is a little different. Surgery to open up the space does improve pain and day to day function for people whose symptoms persist despite good conservative care. The evidence is less clear cut for walking distance specifically, which surprises people, since that is often the thing they most want back.

Either way:

• There is no rush for most people, and waiting does not spoil your chances.
• The decision should be based on what you can and cannot do, not on how the scan looks.
• The exceptions are urgent. Cauda equina syndrome and weakness that is getting worse are not wait and see situations. See section 14.

10. A word about painkillers

I am not your prescriber, and this is not prescribing advice. But two things are worth knowing.

First, national guidance advises against gabapentin and pregabalin for sciatica, along with steroid tablets and diazepam type drugs, on the grounds that there is no overall evidence of benefit and there is evidence of harm. Opioids are also not recommended for long lasting sciatica. Many people are on these. Please do not stop anything on the strength of this guide, because some need reducing gradually. Take it to your GP and ask.

Second, anti-inflammatory tablets like ibuprofen and naproxen carry noticeably higher risks after sixty. Stomach bleeding, kidney problems and raised blood pressure, plus interactions with blood pressure tablets, water tablets and blood thinners. Gels rubbed into the skin carry much less risk.

Anything that makes you drowsy or light headed feeds straight into falls risk.

If you take painkillers regularly rather than now and then, a free medicines review with your pharmacist is a genuinely useful half hour.

11. Strength is the thing, and it is not too late

If you take one practical action from this guide, make it this one.

From around fifty we lose muscle and strength steadily, and strength goes faster than bulk. Left alone it accelerates. That is the main reason a back that coped at fifty five struggles at seventy: not that the spine wore out, but that everything around it got weaker while life stayed the same.

Here is the part people are rarely told. You can get it back, at any age. Strength training builds strength and function in people in their seventies, eighties and nineties. The trials have been done, including in frail care home residents. You are not too old and you are not too late.

• The NHS advice for adults over 65 is strength, balance and flexibility work on at least two days a week, plus 150 minutes a week of moderate activity.
• Strength work means real resistance. Weights, bands, or bodyweight moves done until the last few repetitions are genuinely hard. Walking is valuable but it does not build strength.
• Standing up from a chair without using your hands is a superb exercise and needs no equipment. It trains exactly what you need for getting off a toilet, out of a car, and up from the floor.
• Balance work matters just as much, because confidence on your feet does as much for pain as anything.
• Start lighter than you think. Soreness for a day or two after starting is normal, and it is not damage.

Getting weaker, not the state of your discs, is what is most likely to take your independence.

12. Moving, pacing and flare-ups

Moving is safe, and resting is the risk. A week in bed costs a younger person some fitness. It costs you muscle, bone, balance and confidence, and it costs them fast.

Some soreness while you build back up is expected. Pain that rises while you move and settles back to normal within about a day is fine. Pain still up the next day means you did a bit too much, not that you did harm.

Pacing is how you avoid the boom and bust:

• Work out what you could manage on almost any day, including a bad one.
• Do that amount consistently, good days and bad.
• Once it feels easy, add about a tenth more each week.
• Break jobs into chunks, with breaks built in before you need them.

Flare-ups are normal and do not mean new damage. Keep moving gently, drop back to your baseline for a few days, use whatever settles it, and remind yourself that this has settled before.

Get in touch if it is not settling as it normally does, or if anything in section 14 applies.

13. What treatment does, and what it does not

Hands-on treatment works through everything above. It closes the gate. It calms the sensitivity. It relaxes muscles that have tightened to protect you. It gives you a spell where moving feels easier and safer. That is a real effect and it is worth having.

What it does not do is widen a narrowed canal, reverse wear, or push a disc back in. Nothing is out of place. Anyone who tells you they can pop a disc back in is describing something that does not happen.

Think of a session as a window: a stretch of time where you can move more freely, and use that freedom to build strength and keep your fitness. The moving and the strengthening are what change things in the long run.

I will adapt what I do to you. Technique, positioning and force all change depending on your bone strength, your medicines and your other conditions, and I will always ask. Please tell me if you have osteoporosis, take blood thinners or long term steroids, or have had spinal surgery.

One note on progress. Pain scores bounce around and can be disheartening. Better questions: how far can I walk before I have to stop? How long before it eases when I sit? Can I get out of a low chair, manage the stairs, do the shop? Function usually improves before pain does, and function is what actually matters.

14. When to get urgent help

Almost all back and leg pain is not an emergency. A few things are, and a few of them get more common with age.

Go straight to A&E, or call 999

• Do not wait to see if these settle. If you are offered a routine appointment, say you are worried about cauda equina syndrome and ask to be seen today.
• Numbness or a changed feeling between your legs, around your back passage or genitals. Including toilet paper feeling different when you wipe.
• Trouble starting to wee. Not being able to feel it coming out. Losing the feeling of a full bladder. Any new loss of control of your bladder or bowels.
• New numbness during sex, or new trouble getting an erection.
• Sciatica in both legs at once, or sciatica that has spread from one leg to the other.
• New or quickly worsening weakness in one or both legs, or your legs giving way.
• Sudden severe pain in your back or tummy with faintness, a cold sweat, or a throbbing feeling in your tummy. This can mean a problem with the main artery in the abdomen, and it is more likely in men over 65, smokers and ex-smokers, and with high blood pressure.
• Severe pain straight after a bad fall or accident.

Contact your GP or NHS 111 today

• Weakness that is getting worse, especially if your foot is starting to drag or catch, or you cannot lift the front of your foot properly.
• Sudden severe back pain after a minor fall, a bump, a cough or a sneeze, or with no cause at all. Especially with osteoporosis, long term steroids, or a previous fracture from a minor injury. This can be a spinal fracture. It is common, treatable, and often missed.
• Losing height, or your upper back becoming noticeably more rounded, alongside back pain.
• Back pain with a fever, shivering, or feeling generally unwell.
• Back pain with weight loss you cannot explain, night sweats, or a past history of any cancer.
• Pain that is much worse at night, wakes you every night, or is not eased by any change of position.

Worth mentioning at a normal appointment

• Exactly what relieves your leg pain. See sections 4 and 5. It is the most useful thing you can tell me.
• Any fall, even one that did not hurt you. Falls are the best predictor of future falls, and your GP can refer you to a falls prevention service.
• Whether you have had a bone density scan, if you have broken a bone from a minor fall since you were fifty.
• Cold feet, leg cramps on walking, or slow healing sores on your feet or legs.

Everything else, including a bad flare-up, can wait for a normal appointment.

15. If you want to read or watch more

Start here

• Tame the Beast. A five minute animation by Professor Lorimer Moseley. The best possible starting point. tamethebeast.org
• Flippin' Pain. A UK campaign about long lasting pain. flippinpain.co.uk
• NHS advice on sciatica. nhs.uk/conditions/sciatica
• NHS activity guidelines for older adults. nhs.uk/live-well/exercise/physical-activity-guidelines-older-adults

Practical help

• The Pain Toolkit, by Pete Moore. Very good on pacing and boom and bust. paintoolkit.org
• Recovery Strategies, by Greg Lehman. A free illustrated workbook. greglehman.ca/recovery-strategies-pain-guidebook
• Age UK, on staying steady, and strength and balance exercises. ageuk.org.uk
• Royal Osteoporosis Society, if bone health matters for you. theros.org.uk

Books

• Explain Pain, by David Butler and Lorimer Moseley.
• The Explain Pain Handbook: Protectometer, by the same authors.

The research behind this guide

• Melzack R, Wall PD. Pain mechanisms: a new theory. Science, 1965. The original pain gate paper.
• Chiu CC et al. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clinical Rehabilitation, 2015. The disc shrinkage figures in section 7.
• Brinjikji W et al. Imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 2015. The scan figures in section 6.
• Jensen RK et al. Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis. European Spine Journal, 2020. The stenosis prevalence figures in section 6.
• Kalichman L et al. Spinal stenosis prevalence and association with symptoms: the Framingham Study. The Spine Journal, 2009.
• Fiatarone MA et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. New England Journal of Medicine, 1994. The classic proof that strength training works in the very old.
• NICE guideline NG59: Low back pain and sciatica in over 16s. The medication advice in section 10 comes from this.
• NICE guideline NG259: Osteoporosis, risk assessment.

Bring any of this to your next appointment. Especially the parts that did not sit right, or that felt uncomfortably familiar.

This guide is general information. It does not replace the advice I give you in clinic.